Basic Information
| Provider Information | |||||||||
| NPI: | 1760681985 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.I.S.A.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4041 N. CENTRAL AVE | ||||||||
| Address2: | BUILDING C | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850123133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022795262 | ||||||||
| FaxNumber: | 6022795390 | ||||||||
| Practice Location | |||||||||
| Address1: | 4041 N. CENTRAL AVE | ||||||||
| Address2: | BUILDING C | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850123133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022795262 | ||||||||
| FaxNumber: | 6022795390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 09/05/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LISAC11403 | AZ | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | LISAC-11403 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 910217 | 05 | AZ | MEDICAID |